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20-10-2020 | Osteoarthritis | News

Outpatient rehabilitation no better than home exercise for TKA recovery

Author: Laura Cowen

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medwireNews: Outpatient therapist-led rehabilitation offers no clinical benefit over a home-based exercise regimen in patients with knee osteoarthritis at risk for poor outcomes after total knee arthroplasty (TKA), shows the TRIO trial.

Writing in The BMJ, David Hamilton (University of Edinburgh, UK) and co-authors say: “Although targeting rehabilitation interventions to at risk patients is a feasible delivery method, the content of the rehabilitation seems to have minimal influence on patient outcomes.”

The TRIO study included 334 participants with knee osteoarthritis who were at risk for a poor outcome after TKA (Oxford knee score of ≤26 points at 6 weeks after surgery).

Of these, 163 were randomly assigned to physiotherapist-led outpatient rehabilitation, which involved six weekly face-to-face, progressive goal-oriented functional rehabilitation sessions plus a further two sessions of personalized rehabilitation each week at home.

The remaining 171 patients were assigned to undertake 18 sessions of home-based rehabilitation, over 6 weeks, that focused on unloaded bending of the knee to promote range of motion and using the weight of the limb to strengthen the quadriceps muscle.

Hamilton and team report that the treatment adherence rates were 85.3% in the physiotherapist-led group and 97.7% in the home exercise group.

At 52 weeks, the average Oxford knee score had improved from 20.40 to 33.55 points in the physiotherapist-led group and from 20.08 to 31.57 points in the home exercise group, with both improvements in excess of the 4-point minimum clinically important difference.

However, the mean difference in improvement between the two groups was just 1.91 points, in favor of the outpatient rehabilitation arm, and was therefore neither clinically nor statistically significant.

There were also no significant postoperative differences between the two groups in the timed get up-and go test or in average pain or worst pain at 52 weeks or at earlier time points.

Furthermore, there was no significant between-group difference in patient satisfaction with outcome or post-intervention function, but individuals in the physiotherapist-led group were significantly more likely than those in the home exercise group to report satisfaction with pain relief (odds ratio [OR]=1.66), ability to perform daily functional tasks (OR=1.66), and ability to perform heavy functional tasks (OR=1.57).

Hamilton et al note that their study was limited by a lack of a “no treatment” comparator group, but despite “debate about the effectiveness of physiotherapy after total knee arthroplasty, and ambiguity about the best delivery method, it remains an accepted component of the treatment pathway for knee arthroplasty in the UK.”

“As such it was considered unethical to include a control group of high risk participants who would not receive physiotherapy,” they say.

The researchers conclude that the finding of “no additional benefit of physical outpatient rehabilitation compared with single physiotherapist review and [home-based exercise] could have implications for healthcare delivery and resource planning around this high volume procedure.”

medwireNews is an independent medical news service provided by Springer Healthcare Ltd. © 2020 Springer Healthcare Ltd, part of the Springer Nature Group

BMJ 2020; 371: m3576

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